The effect of the Attachment and Biobehavioural Catch-up parenting intervention for children with intellectual disabilities in South Africa

Abstract

The research presented in this thesis spans the fields of attachment-based interventions and intellectual disabilities (ID), and encompasses four studies. The first study aimed to distil the practice elements across attachment-based interventions and match patterns of practice elements to child characteristics. This was approached using a literature-based, systematic review methodology. Guided by the Distillation and Matching Model, the practice elements common across 45 effective attachment-based interventions, as reported in 60 published studies, were distilled and subsequently matched to key child variables--child age, ethnicity, location and risk status--to examine how profiles of practice elements associated with each variable may be distinct, or similar. The findings suggest that while there was notable similarity across practice element profiles in terms of the use of relationship-building, video-feedback, psychoeducation and home-based approaches, some distinctions were observed. Interventions for younger infants frequently involved direct demonstration and modelling, while those for older infants and young children consisted of feedback-based approaches. Interventions for vulnerable, at-risk parents consisted of intensive guidance, while those for groups indigenous to North America benefitted from a comprehensive and multifaceted package of practice elements. Finally, interventions for adolescent-aged children were frequently implemented in parent-group format, involving role-plays and discussions between parents, with limited direct involvement of the child. These distinctions may inform differential clinical applications of attachment-based interventions informed by the needs of specific populations. In the second study, the aims were two-fold: i) to explore the parenting-related challenges, perceptions of current care and needs of caregivers of children with ID in South Africa; and ii) to obtain expert/professional opinion and input on the challenges and needs/wishes of caregivers of children with ID. Forty South African primary caregivers of children with ID and five health professionals working in the field of ID took part in this mixed-methods study. All caregivers completed measures of parenting stress, parenting self-efficacy, support networks and perceptions of current healthcare services. A subset of 10 caregivers and the five health professionals also participated in semi-structured interviews. Data were analysed through descriptive statistics and thematic analysis. The findings suggest that parents of children with ID in South Africaexperienced noteworthy parenting-related stress and lowered parenting-related self-efficacy. Explanations for this by caregivers and professionals focused on experiences of criticism from significant others, lack of assistance from individuals and institutions, difficulties with understanding their child's needs, and difficulties in coming to terms with their child's diagnosis. Caregivers received support from multiple sources, expressing satisfaction with healthcare services for their child with ID. However, they also highlighted gaps relating to caregiver-focused support for building their relationships with their children and fostering their development and wellbeing. This underscores the need for relationally-oriented The third study sought to evaluate the effects of an established attachment-based intervention--Attachment and Biobehavioral Catch-up (ABC)--on maternal sensitivity, attachment security, and child affect/cortisol regulation in dyads in which the child had significant developmental delays/ID. A single-case, mixedmethods, concurrent multiple-baseline study was conducted across three parent-child dyads. Weekly repeated measures of the primary outcome variables were conducted to measure change over time, and semi-structured interviews were conducted with the parents and intervenors following the completion of the intervention. Quantitative data were analysed using visual analysis as well as statistically, using randomisation testing. Results showed improvements in maternal sensitivity and attachment security over time and across dyads, but results on cortisol regulation were inconclusive. However, the intervention effects observed through visual analysis and inspection were not confirmed by the statistical analyses. Thequalitative data were analysed using thematic analysis and showed that the intervention was positively received, was found to be relevant and helpful, and that both the parents and intervenors observed positive changes in the nature of the parent-child interactions over the course of the intervention, highlighting the social validity of the ABC. Therefore, the findings on the effects of the ABC for this cohort of children are tentative but promising. In the fourth and final study, the aim was to obtain expert/professional opinion, and caregiver impressions, on the ABC intervention to inform potential adaptations for the population of children with ID and the local South African context. To do this, an exploratory qualitative study, with an embedded adapted qualitative Delphi component, was conducted. The three parents and two intervenors involved with the ABC, an additional group of eight parents of children with ID not involved with the ABC, and a panel of five experts participated in semi-structured interviews and were asked to provide comment and opinion on the ABC.Subsequently, as part of the adapted Delphi component, the five experts were requested to provide written feedback on a preliminary analysis of their initial interviews, to facilitate consensus. The data were analysed using thematic analysis. Overall, there was notable support for the ABC. The strengths-based andsupportive coaching approach combined with reinforcing feedback was considered to foster a safe environment for caregivers of children with ID/DD. This facilitated significant learnings for those who received the ABC. Coaches were similarly supported through quality supervision and encouraged by caregiver commitment to the process. Some key recommendations included, amongst others, training coaches in identifying the anomalous communication styles of children with ID and in activating referral networks, identifying and training local and community-based coaches and partnering with NGOs to address logistical as well as context- and culture-related factors involved in implementing the ABC in a novel setting. Interventions for parents and their children with ID in South Africa.